Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond.

Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.

Scale-up of collaborative TB/HIV activities in Guyana.

OBJECTIVE: To assess scale-up of recommended tuberculosis (TB)/HIV activities in Guyana and to identify specific strategies for further expansion. METHODS: Medical records and clinic registers were reviewed at nine TB clinics and 10 HIV clinics. At TB clinics, data were collected on HIV testing and antiretroviral therapy (ART) for patients with TB/HIV; at HIV clinics, data were collected on intensified case finding (ICF), tuberculin skin test (TST) results, and provision of isoniazid preventive therapy (IPT). RESULTS: At TB clinics, among 461 patients newly diagnosed with TB, 419 (90.9%) had a known HIV status and 121 (28.9%) were HIV-infected. Among the 63 patients with TB/HIV, 33 (52.4%) received ART. Among the 45 patients with TB/HIV for whom dates of HIV diagnosis were available, 38 (84.4%) individuals knew their HIV status prior to TB diagnosis. At HIV clinics, among 127 patients eligible to receive a TST, 87 (68.5%) received a TST, 66 (75.9%) had a TST result, seven (10.6%) had a newly positive result, two had a previously positive result, and six of nine patients with positive results (66.7%) received IPT. ICF could not be assessed because of incomplete or discrepant documentation. CONCLUSIONS: An in-depth evaluation of TB/HIV activities successfully identified areas of success and remaining challenges. At TB clinics, HIV testing rates are high; further scale-up of ART for persons with TB/HIV is needed. At HIV clinics, use of TST to focus IPT is a feasible and efficient strategy; improving rates of annual TST screening will allow for further expansion of IPT.

Scale-up of collaborative TB/HIV activities in Guyana / Ampliar las actividades de colaboración contra la tuberculosis y la infección por el VIH en Guyana

Objective. To assess scale-up of recommended tuberculosis (TB)/HIV activities in Guyana and to identify specific strategies for further expansion. Methods. Medical records and clinic registers were reviewed at nine TB clinics and 10 HIV clinics. At TB clinics, data were collected on HIV testing and antiretroviral therapy (ART) for patients with TB/HIV; at HIV clinics, data were collected on intensified case finding (ICF), tuberculin skin test (TST) results, and provision of isoniazid preventive therapy (IPT). Results. At TB clinics, among 461 patients newly diagnosed with TB, 419 (90.9%) had a known HIV status and 121 (28.9%) were HIV-infected. Among the 63 patients with TB/HIV, 33 (52.4%) received ART. Among the 45 patients with TB/HIV for whom dates of HIV diagnosis were available, 38 (84.4%) individuals knew their HIV status prior to TB diagnosis. At HIV clinics, among 127 patients eligible to receive a TST, 87 (68.5%) received a TST, 66 (75.9%) had a TST result, seven (10.6%) had a newly positive result, two had a previously positive result, and six of nine patients with positive results (66.7%) received IPT. ICF could not be assessed because of incomplete or discrepant documentation. Conclusions. An in-depth evaluation of TB/HIV activities successfully identified areas of success and remaining challenges. At TB clinics, HIV testing rates are high; further scale-up of ART for persons with TB/HIV is needed. At HIV clinics, use of TST to focus IPT is a feasible and efficient strategy; improving rates of annual TST screening will allow for further expansion of IPT.

Objetivo. Evaluar la ampliación de las actividades recomendadas contra la tuberculosis (TB) y la infección por el VIH en Guyana y definir estrategias específicas para nuevas expansiones. Métodos. Se examinaron los expedientes médicos y registros clínicos de nueve consultorios de atención de la TB y diez consultorios de atención de la infección por el VIH. En los consultorios de atención de la tuberculosis, se recopilaron datos sobre las pruebas de detección del VIH y el tratamiento antirretroviral (TAR) para pacientes con TB e infección por el VIH; en los consultorios de atención de la infección por VIH, se recopilaron datos a partir de una búsqueda intensiva de casos, los resultados de la prueba de la tuberculina y la provisión de tratamiento preventivo con isoniazida. Resultados. En los consultorios de atención de la tuberculosis, de 461 pacientes recién diagnosticados con tuberculosis, 419 (90,9%) conocían su estado con respecto a la infección por el VIH y 121 (28,9%) estaban infectados por el virus. De los 63 pacientes con TB e infección por el VIH, 33 (52,4%) recibieron TAR. De los 45 pacientes con TB e infección por el VIH cuya fecha de diagnóstico de la infección por el VIH se conocía, 38 (84,4%) supieron de su estado con respecto a la infección por el VIH antes de recibir el diagnóstico de la tuberculosis. En los consultorios de atención de la infección por el VIH, de 127 pacientes que reunían los requisitos para la prueba de la tuberculina, 87 (68,5%) recibieron la prueba, 66 (75,9%) tuvieron un resultado, siete (10,6%) tuvieron un resultado positivo nuevo, dos habían tenido un resultado positivo anteriormente, y seis de nueve pacientes con resultados positivos (66,7%) recibieron tratamiento preventivo con isoniazida. No pudo evaluarse la búsqueda intensiva de casos debido a que la documentación estaba incompleta o era discrepante. Conclusiones. Una evaluación exhaustiva de las actividades contra la TB y la infección por el VIH permitió determinar las áreas donde se había tenido éxito y los retos pendientes. En los consultorios de atención de la tuberculosis, las tasas de realización de pruebas de detección del VIH son elevadas; se necesita ampliar el alcance del TAR para llegar a las personas con TB e infección por el VIH. En los consultorios de atención de la infección por el VIH, el uso de la prueba de la tuberculina para focalizar la búsqueda intensiva de casos es una estrategia factible y eficaz; el mejoramiento de las tasas de tamizaje anual con la prueba de la tuberculina permitirá ampliar la búsqueda intensiva de casos.

Scale-up of collaborative TB/HIV activities in Guyana / Ampliar las actividades de colaboración contra la tuberculosis y la infección por el VIH en Guyana

ABSTRACT Objective To assess scale-up of recommended tuberculosis (TB)/HIV activities in Guyana and to identify specific strategies for further expansion. Methods Medical records and clinic registers were reviewed at nine TB clinics and 10 HIV clinics. At TB clinics, data were collected on HIV testing and antiretroviral therapy (ART) for patients with TB/HIV; at HIV clinics, data were collected on intensified case finding (ICF), tuberculin skin test (TST) results, and provision of isoniazid preventive therapy (IPT). Results At TB clinics, among 461 patients newly diagnosed with TB, 419 (90.9%) had a known HIV status and 121 (28.9%) were HIV-infected. Among the 63 patients with TB/HIV, 33 (52.4%) received ART. Among the 45 patients with TB/HIV for whom dates of HIV diagnosis were available, 38 (84.4%) individuals knew their HIV status prior to TB diagnosis. At HIV clinics, among 127 patients eligible to receive a TST, 87 (68.5%) received a TST, 66 (75.9%) had a TST result, seven (10.6%) had a newly positive result, two had a previously positive result, and six of nine patients with positive results (66.7%) received IPT. ICF could not be assessed because of incomplete or discrepant documentation. Conclusions An in-depth evaluation of TB/HIV activities successfully identified areas of success and remaining challenges. At TB clinics, HIV testing rates are high; further scale-up of ART for persons with TB/HIV is needed. At HIV clinics, use of TST to focus IPT is a feasible and efficient strategy; improving rates of annual TST screening will allow for further expansion of IPT.

RESUMEN Objetivo Evaluar la ampliación de las actividades recomendadas contra la tuberculosis (TB) y la infección por el VIH en Guyana y definir estrategias específicas para nuevas expansiones. Métodos Se examinaron los expedientes médicos y registros clínicos de nueve consultorios de atención de la TB y diez consultorios de atención de la infección por el VIH. En los consultorios de atención de la tuberculosis, se recopilaron datos sobre las pruebas de detección del VIH y el tratamiento antirretroviral (TAR) para pacientes con TB e infección por el VIH; en los consultorios de atención de la infección por VIH, se recopilaron datos a partir de una búsqueda intensiva de casos, los resultados de la prueba de la tuberculina y la provisión de tratamiento preventivo con isoniazida. Resultados En los consultorios de atención de la tuberculosis, de 461 pacientes recién diagnosticados con tuberculosis, 419 (90,9%) conocían su estado con respecto a la infección por el VIH y 121 (28,9%) estaban infectados por el virus. De los 63 pacientes con TB e infección por el VIH, 33 (52,4%) recibieron TAR. De los 45 pacientes con TB e infección por el VIH cuya fecha de diagnóstico de la infección por el VIH se conocía, 38 (84,4%) supieron de su estado con respecto a la infección por el VIH antes de recibir el diagnóstico de la tuberculosis. En los consultorios de atención de la infección por el VIH, de 127 pacientes que reunían los requisitos para la prueba de la tuberculina, 87 (68,5%) recibieron la prueba, 66 (75,9%) tuvieron un resultado, siete (10,6%) tuvieron un resultado positivo nuevo, dos habían tenido un resultado positivo anteriormente, y seis de nueve pacientes con resultados positivos (66,7%) recibieron tratamiento preventivo con isoniazida. No pudo evaluarse la búsqueda intensiva de casos debido a que la documentación estaba incompleta o era discrepante. Conclusiones Una evaluación exhaustiva de las actividades contra la TB y la infección por el VIH permitió determinar las áreas donde se había tenido éxito y los retos pendientes. En los consultorios de atención de la tuberculosis, las tasas de realización de pruebas de detección del VIH son elevadas; se necesita ampliar el alcance del TAR para llegar a las personas con TB e infección por el VIH. En los consultorios de atención de la infección por el VIH, el uso de la prueba de la tuberculina para focalizar la búsqueda intensiva de casos es una estrategia factible y eficaz; el mejoramiento de las tasas de tamizaje anual con la prueba de la tuberculina permitirá ampliar la búsqueda intensiva de casos.

Abrupt Decline in Tuberculosis among Foreign-Born Persons in the United States.

While the number of reported tuberculosis (TB) cases in the United States has declined over the past two decades, TB morbidity among foreign-born persons has remained persistently elevated. A recent unexpected decline in reported TB cases among foreign-born persons beginning in 2007 provided an opportunity to examine contributing factors and inform future TB control strategies. We investigated the relative influence of three factors on the decline: 1) changes in the size of the foreign-born population through immigration and emigration, 2) changes in distribution of country of origin among foreign-born persons, and 3) changes in the TB case rates among foreign-born subpopulations. Using data from the U.S. National Tuberculosis Surveillance System and the American Community Survey, we examined TB case counts, TB case rates, and population estimates, stratified by years since U.S. entry and country of origin. Regression modeling was used to assess statistically significant changes in trend. Among foreign-born recent entrants (<3 years since U.S. entry), we found a 39.5% decline (-1,013 cases) beginning in 2007 (P<0.05 compared to 2000-2007) and ending in 2011 (P<0.05 compared to 2011-2014). Among recent entrants from Mexico, 80.7% of the decline was attributable to a decrease in population, while the declines among recent entrants from the Philippines, India, Vietnam, and China were almost exclusively (95.5%-100%) the result of decreases in TB case rates. Among foreign-born non-recent entrants (≥3 years since U.S. entry), we found an 8.9% decline (-443 cases) that resulted entirely (100%) from a decrease in the TB case rate. Both recent and non-recent entrants contributed to the decline in TB cases; factors contributing to the decline among recent entrants varied by country of origin. Strategies that impact both recent and non-recent entrants (e.g., investment in overseas TB control) as well as those that focus on non-recent entrants (e.g., expanded targeted testing of high-risk subgroups among non-recent entrants) will be necessary to achieve further declines in TB morbidity among foreign-born persons.

Notes from the field: use of genotyping to disprove a presumed outbreak of Mycobacterium tuberculosis - Los Angeles County, 2013-2014.

In early 2013, the Los Angeles County Department of Public Health learned of two patients diagnosed with tuberculosis (TB) who had received care at the same outpatient health care facility (facility A). Facility A is a center for infusions of chemotherapeutic and biologic agents and serves a large number of immunocompromised persons who were potentially exposed to infectious TB. If infected, immunocompromised persons are at elevated risk for progression to TB disease. The two patients (patient A and patient B) both had pulmonary TB, with acid-fast bacilli found on sputum-smear microscopy, and had visited facility A multiple times during their infectious periods. Despite initial concerns that these two cases could be the result of person-to-person transmission at facility A, genotyping of the Mycobacterium tuberculosis isolates from these two patients showed that they were infected with unrelated strains.

Decline in tuberculosis among Mexico-born persons in the United States, 2000-2010.

BACKGROUND: In 2010, Mexico was the most common (22.9%) country of origin for foreign-born persons with tuberculosis in the United States, and overall trends in tuberculosis morbidity are substantially influenced by the Mexico-born population. OBJECTIVES: To determine the risk of tuberculosis disease among Mexico-born persons living in the United States. METHODS: Using data from the U.S. National Tuberculosis Surveillance System and the American Community Survey, we examined tuberculosis case counts and case rates stratified by years since entry into the United States and geographic proximity to the United States-Mexico border. We calculated trends in case rates over time measured by average annual percent change. RESULTS: The total tuberculosis case count (-14.5%) and annual tuberculosis case rate (average annual percent change -5.1%) declined among Mexico-born persons. Among those diagnosed with tuberculosis less than 1 year since entry into the United States (newly arrived persons), there was a decrease in tuberculosis cases (-60.4%), no change in tuberculosis case rate (average annual percent change of 0.0%), and a decrease in population (-60.7%). Among those living in the United States for more than 5 years (non-recently arrived persons), there was an increase in tuberculosis cases (+3.4%), a decrease in tuberculosis case rate (average annual percent change of -4.9%), and an increase in population (+62.7%). In 2010, 66.7% of Mexico-born cases were among non-recently arrived persons, compared with 51.1% in 2000. Although border states reported the highest proportions (>15%) of tuberculosis cases that were Mexico-born, the highest Mexico-born-specific tuberculosis case rates (>20/100,000 population) were in states in the eastern and southeastern regions of the United States. CONCLUSIONS: The decline in tuberculosis morbidity among Mexico-born persons may be attributed to fewer newly arrived persons from Mexico and lower tuberculosis case rates among non-recently arrived Mexico-born persons. The extent of the decline was dampened by an unchanged tuberculosis case rate among newly arrived persons from Mexico and a large increase in the non-recently arrived Mexico-born population. If current trends continue, tuberculosis morbidity among Mexico-born persons will be increasingly driven by those who have been living in the United States for more than 5 years.

Elevated corrosion rates and hydrogen sulfide in homes with 'Chinese Drywall'.

In December 2008, the U.S. Consumer Product Safety Commission (CPSC) began receiving reports about odors, corrosion, and health concerns related to drywall originating from China. In response, a detailed environmental health and engineering evaluation was conducted of 41 complaint and 10 non-complaint homes in the Southeast U.S. Each home investigation included characterization of: 1) drywall composition; 2) indoor and outdoor air quality; 3) temperature, moisture, and building ventilation; and 4) copper and silver corrosion rates. Complaint homes had significantly higher hydrogen sulfide concentrations (mean 0.82 vs.

The benefits of whole-house in-duct air cleaning in reducing exposures to fine particulate matter of outdoor origin: a modeling analysis.

Health risks of fine particle air pollution (PM(2.5)) are an important public health concern that has the potential to be mitigated in part by interventions such as air cleaning devices that reduce personal exposure to ambient PM(2.5). To characterize exposure to ambient PM(2.5) indoors as a function of residential air cleaners, a multi-zone indoor air quality model was used to integrate spatially resolved data on housing, meteorology, and ambient PM(2.5), with performance testing of residential air cleaners to estimate short-term and annual average PM(2.5) of outdoor origin inside residences of three metropolitan areas. The associated public health impacts of reduced ambient PM(2.5) exposure were estimated using a standard health impact assessment methodology. Estimated indoor levels of ambient PM(2.5) varied substantially among ventilation and air cleaning configurations. The median 24-h average indoor-outdoor ratio of ambient PM(2.5) was 0.57 for homes with natural ventilation, 0.35 for homes with central air conditioning (AC) with conventional filtration, and 0.1 for homes with central AC with high efficiency in-duct air cleaner. Median modeled 24-h average indoor concentrations of PM(2.5) of outdoor origin for those three configurations were 8.4, 5.3, and 1.5 microg/m(3), respectively. The potential public health benefits of reduced exposure to ambient PM(2.5) afforded by air cleaning systems were substantial. If the entire population of single-family homes with central AC in the modeling domain converted from conventional filtration to high-efficiency in-duct air cleaning, the change in ambient PM(2.5) exposure is estimated to result in an annual reduction of 700 premature deaths, 940 hospital and emergency room visits, and 130,000 asthma attacks in these metropolitan areas. In addition to controlling emissions from sources, high-efficiency whole-house air cleaner are expected to reduce exposure to particles of outdoor origin and are projected to be an effective means of managing public health impacts of ambient particle pollution.

Whole house particle removal and clean air delivery rates for in-duct and portable ventilation systems.

A novel method for determining whole house particle removal and clean air delivery rates attributable to central and portable ventilation/air cleaning systems is described. The method is used to characterize total and air-cleaner-specific particle removal rates during operation of four in-duct air cleaners and two portable air-cleaning devices in a fully instrumented test home. Operation of in-duct and portable air cleaners typically increased particle removal rates over the baseline rates determined in the absence of operating a central fan or an indoor air cleaner. Removal rates of 0.3- to 0.5-microm particles ranged from 1.5 hr(-1) during operation of an in-duct, 5-in. pleated media filter to 7.2 hr(-1) for an in-duct electrostatic air cleaner in comparison to a baseline rate of 0 hr(-1) when the air handler was operating without a filter. Removal rates for total particulate matter less than 2.5 microm in aerodynamic diameter (PM2.5) mass concentrations were 0.5 hr(-1) under baseline conditions, 0.5 hr(-1) during operation of three portable ionic air cleaners, 1 hr(-1) for an in-duct 1-in. media filter, 2.4 hr(-1) for a single high-efficiency particle arrestance (HEPA) portable air cleaner, 4.6 hr(-1) for an in-duct 5-in. media filter, 4.7 hr(-1) during operation of five portable HEPA filters, 6.1 hr(-1) for a conventional in-duct electronic air cleaner, and 7.5 hr(-1) for a high efficiency in-duct electrostatic air cleaner. Corresponding whole house clean air delivery rates for PM2.5 attributable to the air cleaner independent of losses within the central ventilation system ranged from 2 m3/min for the conventional media filter to 32 m3/min for the high efficiency in-duct electrostatic device. Except for the portable ionic air cleaner, the devices considered here increased particle removal indoors over baseline deposition rates.

Airborne fungal spores in a cross-sectional study of office buildings.

Airborne fungal spores were measured in 44 office buildings in the summer and winter throughout the continental United States, as part of the Building Assessment, Survey and Evaluation (BASE) program. Six indoor air and two outdoor air samples were collected on a single day from each building. The cross-sectional and repeated measure design afforded evaluation of between-building and within-building variability of fungal spore levels in buildings. Total fungal spore concentrations in indoor air ranged from < 24 to 1000 spores/m3, except for one building with natural ventilation where indoor levels were approximately 9000 spores/m3. Indoor air concentrations of total spores did not vary significantly between winter and summer or morning and afternoon monitoring periods or among climate zones or locations within a test area. Indoor-outdoor ratios of total spore concentrations typically ranged between 0.01 and 0.1 and were approximately seven times greater in winter than summer because of relatively low outdoor levels in the winter. The indoor-outdoor ratio of total spore concentrations for a building was consistent (reliability coefficient = 0.91) among repeated measures. Distributions of rank correlation coefficients for spore types in pairs of individual indoor-outdoor and indoor-indoor samples were weakly correlated (Spearman correlation = 0.2 on average). When spore type data were aggregated among samples from the same building, the central tendency of the rank correlation coefficients increased to 0.45. Rank correlation coefficients were also proportional to the number of spore types present in the samples that were compared. The BASE study provides normative data on concentrations of fungal spores that can aid in identification of problematic levels of mold in buildings.